Clinical Insights About Onychomycosis and Its Treatment: A Consensus

March 2018 | Volume 17 | Issue 3 | Original Article | 253 | Copyright © March 2018

Sam Hanna MD DABD,a Anneke Andriessen PhD,b Jennifer Beecker MD CCFP (EM) FRCPC DABD,c Martin Gilbert MD FRCPC,d Eric Goldstein MD FRCPC,e Sunil Kalia MD FRCPC,f Aaron King MD FRCPC,g John Kraft MD,h Carrie Lynde MD FRCPC,i Davindra Singh MD FRCPC,j Irina Turchin MD FRCPC,k and Catherine Zip MD FRCPC l

aAmerican Board of Dermatology, Canadian Dermatology Association’s Pharmacy and Therapeutics Committee, Toronto, ON, Canada bRadboud UMC, Nijmegen, The Netherlands; Andriessen Consultants, Malden, The Netherlands cDivision of Dermatology, The Ottawa Hospital, Ottawa, Canada dQuebec, Que, Canada eToronto, ON, Canada fVancouver, BC, Canada gToronto, ON, Canada hValeant, Markham, ON, Canada iMarkham, ON, Canada jAvantDerm, Toronto, ON, Canada kBrunswick Dermatology Center, Fredericton, NB, Canada lCalgary, AB, Canada

BACKGROUND: Recently, experience and knowledge have been gained using effective topical treatment for onychomycosis, a difficult-to-treat infection. METHODS: This project aims to help understand and improve patient-focused quality of care for fungal nail infections. A panel of dermatologists who treat onychomycosis convened on several occasions to review and discuss recent learnings in the treatment of onychomycosis. The panel developed and conducted a survey on diagnosis, treatment and prevention, discussed the results, and provided recommendations. RESULTS: The survey was sent out digitally to the Canadian Dermatology community. Ninety-two dermatologists completed the questionnaires, which were included in the analysis. The survey respondents and panel members agreed that the diagnosis of toe onychomycosis should be confirmed with a positive microscopic examination for fungus or a positive mycological culture when oral therapy and/or topical treatment is prescribed, except when it is not clinically feasible, in which case topical therapy could be started based on clinical presentation. The panel and survey respondents also agreed that treatment is to be based on percentage of nail involvement: less than 20%=topical efinaconazole; 20%-60%=topical efinaconazole±oral terbinafine (for greater than 3 nails); greater than 60%=oral terbinafine±topical therapy. CONCLUSIONS: The current treatment paradigm for onychomycosis may have shifted from mainly oral antifungals to topical treatment, improving patient-focused quality of care.

J Drugs Dermatol. 2018;17(3):253-262.


Onychomycosis is a common nail infection which comprises a third of fungal skin infections.1 Fungal nail disease can coexist with other nail disorders.1-3 The prevalence of onychomycosis is higher in people whose occupations or hobbies put them at risk of nail injury, increased sweating, and exposure to pathogens, such as during sports activities, or spa and public swimming pool visits.1,2 Males, smokers, those with previous tinea pedis infection, elderly individuals, and those with conditions such as diabetes, peripheral vascular disease, psoriasis, and immunosuppression (HIV infection or immunosuppressive therapy) also have a higher incidence of nail infections.1,3 Onychomycosis is a difficult-to-treat infection for which the current treatment paradigm has shifted from mainly oral antifungals to include topical or transungual treatment options. A project called Advancing Patient Care in Onychomycosis [APCO] has been developed to help understand and improve patient-focused quality of care for fungal nail infections. In